Arizona Medical Lien Agreement

Make sure your bills get paid. Have your patients sign this Arizona Patient Consent and Medical Lien Agreement at the time of treatment.

• The patient consents to treatment and authorizes release of all medical information with respect to the patient's claim regarding the accident or injury for which the patient is being treated.
• The patient agrees to be personally liable for paying the medical provider's fees regardless of the outcome of the patient's claim.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien out of those proceeds.
• The patient will notify the medical provider if he/she retains new legal counsel.
• Buy the form once, and it's yours to use as often as you require.
• Intended for use only in the State of Arizona.